Provider Demographics
NPI:1851868533
Name:BLANSETT, LORI (NP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BLANSETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4381 S EASON BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6585
Mailing Address - Country:US
Mailing Address - Phone:662-377-6610
Mailing Address - Fax:662-377-6614
Practice Address - Street 1:4381 S EASON BLVD STE 202
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6585
Practice Address - Country:US
Practice Address - Phone:662-377-6610
Practice Address - Fax:662-377-6614
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01906093Medicaid